Energize Sports Massage

Do you get a
sharp, debilitating pain in your shoulder when you are performing tasks like
brushing your hair, putting on certain clothes or showering? During these
movements, where you raise your arm out to the side and then upwards over your
head, do you alternate between no pain and pain? For example, during the first
part of the moment you don’t feel any pain, and then suddenly your shoulder
“catches” and there is sharp pain, followed by no pain again as you continue to
move your arm upwards.

These are all
signs of a condition called Shoulder Impingement Syndrome (SIS), where the
tendons of the rotator cuff muscles that stabilise your shoulder get trapped as
they pass through the shoulder joint in a narrow bony space called the
sub-acromial space. Impingement means to impact or encroach on bone, and
repeated pinching and irritation of these tendons and the bursa (the padding
under the shoulder bone) can lead to injury and pain.

Shoulder complaints are the third most common musculoskeletal
problem after back and neck disorders. The highest incidence is in women
and people aged 45–64 years. Of all shoulder disorders, shoulder impingement
syndrome (SIS) accounts for 36%, making it the most common shoulder injury.

You shouldn’t experience impingement with normal shoulder
function. When it does happen, the rotator cuff tendon becomes inflamed and
swollen, a condition called rotator cuff tendonitis. Likewise, if the bursa
becomes inflamed, you could develop shoulder bursitis. You can experience these
conditions either on their own, or at the same time.

The injury can vary from mild tendon inflammation (tendonitis),
bursitis (inflamed bursa), calcific tendonitis (bone forming within the tendon)
through to partial and full thickness tendon tears, which may require surgery.
Over time the tendons can thicken due to repeated irritation, perpetuating the
problem as the thicker tendons battle to glide through the narrow bony
sub-acromial space. The tendons can even degenerate and change in microscopic
structure, with decreased circulation within the tendon resulting in a chronic
tendonosis.

What Causes
Shoulder Impingement?

Generally, SIS is caused by repeated, overhead movement of your
arm into the “impingement zone,” causing the rotator cuff to
contact the outer tip of the shoulder blade (acromion). When this repeatedly
occurs, the swollen tendon is trapped and pinched under the acromion. The
condition is frequently called Swimmer’s Shoulder or Thrower’s Shoulder, since
the injury occurs from repetitive overhead activities. Injury could also stem
from simple home chores, like hanging washing on the line or a repetitive
activity at work. In other cases, it can be caused by traumatic injury, like a
fall.

Primary Rotator Cuff Impingement is
due to a structural narrowing in the space where the tendons glide. Osteoarthritis,
for example, can cause the growth of bony spurs, which narrow the space. With a
smaller space, you are more likely to squash and irritate the underlying soft
tissues (tendons and bursa).

Secondary Rotator Cuff Impingement is due to an instability in the shoulder girdle. This means that there is a combination of excessive joint
movement, ligament laxity and muscle weakness around the shoulder joint. Poor stabilisation of the shoulder blade by the surrounding
muscles changes the physical position of the bones in the shoulder, which in
turn increases the risk of tendon impingement. Other causes can include
weakening of the rotator cuff tendons due to overuse, for example in throwing
and swimming, or muscle imbalances between the shoulder muscles.

In summary, impingement usually occurs over time
due to repetitive overhead activity, trauma, previous
injury, poor posture or inactivity.

When your rotator cuff fails to work normally, it is unable to
prevent the head of the humerus (upper arm) from riding up into
the shoulder space, causing the bursa or tendons to be squashed.
Failure to properly treat this instability causes the injury to recur. Poor
technique or bad training habits such as training too hard is also a common
cause of overuse injuries.

Over time pain can cause further dysfunction by altering your
shoulder movement patterns which may lead to a frozen shoulder. For this
reason, it is vitally important that shoulder impingement syndrome is rested
and treated as soon as possible to avoid longer term damage and joint
deterioration.

What are the
Symptoms of Shoulder Impingement?

Commonly rotator cuff impingement has the following symptoms:

▪ An
arc of shoulder pain approximately when your arm is at shoulder height and/or
when your arm is overhead

▪ Shoulder
pain that can extend from the top of the shoulder down the arm to the elbow

▪ Pain
when lying on the sore shoulder, night pain and disturbed sleep

▪ Shoulder
pain at rest as your condition worsens

▪ Muscle
weakness or pain when attempting to reach or lift

▪ Pain
when putting your hand behind your back or head

▪ Pain
reaching for the seat-belt, or out of the car window for a parking ticket

Who Suffers
Shoulder Impingement?

Impingement syndrome is more likely to occur in people who
engage in physical activities that require repeated overhead arm movements,
such as tennis, golf, swimming, weight lifting, or throwing a
ball. Occupations that require repeated overhead lifting or work at or
above shoulder height also increase the risk of rotator cuff impingement.

How is
Shoulder Impingement Diagnosed?

Shoulder impingement can be diagnosed by your physical therapist
using some specific manual tests. An ultrasound scan
may be useful to detect any associated injuries such as shoulder bursitis,
rotator cuff tears, calcific tendonitis or shoulder tendinopathies. An x-ray
can be used to see any bony spurs that may have formed and narrowed the
sub-acromial space.

What does the
Treatment Involve?

There are many structures that can be injured in shoulder
impingement syndrome. How the impingement occurred is the most important
question to answer. This is especially important if the onset was gradual,
since your static and dynamic posture, muscle strength, and flexibility all
have important roles to play. Your rotator cuff is an important group of
muscles that control and stabilise the shoulder joint. It is essential the
muscles around the thoracic spine and shoulder blade are also assessed and
treated as these too work together with the entire shoulder girdle.

To effectively rehabilitate this injury and prevent recurrence,
you need to work through specific stages with your therapist.

The early stages of treatment will involve manual therapy,
including massage to relieve pain and release tight structures as well as
mobilisation techniques to restore normal shoulder movement. Strapping/taping
has been shown to be helpful in reducing pain as well as ultrasound and laser
therapy. As you move through the other stages of treatment your therapist will
prescribe rehabilitation exercises specific to your shoulder, posture, sport
and/or work demands.

Corticosteroid injections can be useful in the initial pain
relieving stage if conservative (non-surgical) methods fail to reduce the pain
and inflammation. It is important to note that once your pain settles, it is
important to assess your strength, flexibility, neck and thoracic spine
involvement to ensure that your shoulder impingement does not return once your
injection has worn off.

Some
shoulder impingements will respond positively and quickly to treatment; however
many others can be incredibly stubborn and frustrating, taking between 3-6
months to resolve. There is no specific time frame for
when to progress from each stage to the next. It is also important to note that
each progression must be carefully monitored as attempting to progress too soon
to the next level can lead to re-injury and frustration. For more specific
advice about your shoulder impingement, contact your local physical therapist.

The information contained in this article is intended as general
guidance and information only and should not be relied upon as a basis for
planning individual medical care or as a substitute for specialist medical
advice in each individual case.